BOSTON – New and innovative methodologies for conducting minimally invasive esophagectomy (MIE) offer significantly lower rates of morbidity and mortality than those normally associated with the procedure, as presented by Dr. James D. Luketich at the Focus on Thoracic Surgery: Technical Challenges and Complications meeting of the American Association for Thoracic Surgery.
While Dr. Luketich spent the bulk of his oral presentation going over the specifics of performing MIE, the accompanying literature of his presentation delved into four key studies – performed and published over the last 12 years – which show the efficacy of MIE over the more traditional approaches to esophagectomy.
“There are several different approaches to esophagectomy in general [but] the technique has evolved partly because the tumors have evolved in the United States,” explained Dr. Luketich, chairman of cardiothoracic surgery at the University of Pittsburgh. “We started off laparoscopic [and] thoracoscopic. In my opinion, that was kind of a bad idea [and] we gave that up pretty early on [...] we’re chest surgeons, we put a thoracoscope in, and we loved it.”
However, as Dr. Luketich explained, the increasing lack of experience from new general surgery residents and attendings caused esophagectomy to become the more attractive option, as it was a procedure that everyone had experience with. This began a search for an effective but minimally invasive approach, which has slowly been cultivated and refined over the years.
Luketich discussed the outcome of his 2003 study assessing 222 consecutive patients who have undergone MIE at the University of Pittsburgh. In that study, patients had lower mortality rates (1.4%) and shorter hospital stays (7 days) than those with “most open series” invasive esophagectomy procedures, with a quality of life score 19 months post operation that was similar to preoperative scores and population norms.
The success of this trial led to the development of the intergroup ECOG 222 trial to determine MIE’s viability in a multicenter setting. Out of 104 patients eligible for MIE, 95 underwent the procedure. Median length of stay in intensive care units was 2 days, and hospital stay was 9 days, with a 2.1% 30-day mortality rate. At 35.8 months (the median follow-up time), the estimated 3-year overall survival was 58.4%.
Similar work was done in 2012, also headed by Dr. Luketich. In this trial, outcomes were evaluated in 1,033 consecutive MIE patients in order to assess the differences between “the modified McKeown minimally invasive approach (videothoracoscopic surgery, laparoscopy, neck anastomosis [MIE-neck]) with our current approach [and] a modified Ivor Lewis approach (laparoscopy, videothoracoscopic surgery, chest anastomosis [MIE-chest]).” MIE-neck was performed on 481 (48%) subjects and MIE-chest on 530 (52%) subjects.
Both procedures had similar median length of stay in hospital (8 days) and in the intensive care unit (2 days), with slightly lower rates of recurrent nerve injury in the MIE-chest cohort and mortality rate of 0.9%. The median number of lymph nodes resected was 21, and total operative mortality was 1.68%, leading investigators to conclude that MIE was the “preferred approach” for resection (P less than .001).
Dr. Luketich also briefly discussed the findings of a 2012 study by Dr. S.S. Biere – an open-label, randomized controlled trial at five study centers spread across three countries from June 2009 through March 2011. Fifty-six patients were randomized into cohorts receiving open esophagectomy, and 59 received MIE; all patients were aged 18-75 years and had resectable cancer of the esophagus or gastroesophageal junction.
Results showed a statistically significant decrease in postoperative pneumonia in the MIE cohort (9% vs. 29%; relative risk 0.35, P = 0.005), compared with open esophagectomy in the first two weeks after surgery and lower postoperative pulmonary infection in the entire hospital stay. MIE patients also experienced shorter hospital stays (11 vs. 14 days), higher short-term quality of life scores at 6 weeks post surgery, lower postoperative pain scores, lower operative blood loss, and lower rates of early morbidity.
Dr. Luketich disclosed having a “shareholder relationship” with Express Scripts and Intuitive Surgical.